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Based on review of policies and procedures, job descriptions, facility documents, medical records, and interviews, it was determined that the governing body, legally responsible for the conduct of the hospital, failed to assure that the Chief Executive Officer managed the hospital when:

A 0263 QAPI

The hospital failed to maintain an effective data-driven quality program of quality assessment, when data over a 15 month period revealed that food temperatures could potentially cause food-borne illness resulting in a risk of harm to the patients, and analysis of the data was not conducted: the governing body was provided the data, but failed to ensure that analysis of the dietary data was conducted. The quality committee and the governing body were not aware of the multiple issues within the dietary department.

A 0618 Food and Dietetic Services

Hospital failed to have an organized dietary service as evidenced by:

Tag A 0622

1. failing to ensure that speciality diets for Long Term Acute Care (LTAC)patients contained the proper nutrients specific to the diet ordered for 10 of 10 patients (Pts # 2, 4, 11, 12, 13, 14, 15, 16, 17, and 18), which has a potential risk of harm to the patients if they are not provided required nutrients necessary to ensure proper healing in the disease process .

2. failing to assure that foods were served to patients at appropriate temperatures to avoid potential food-borne illness and risk of harm to the patients.

Tag A 0629

1. that the hospital failed to ensure that patients ordered a specialty diet received nutrition according to the specific dietary order in 10 of 10 patients ordered a specialty diet (Patients #2, 4, 11, 12, 13, 14, 15, 16, 17, and 18) which has a potential risk of harm to the patients if they are not provided the required nutrition identified in each specialty diet; and

2. that the hospital failed to meet the patient's needs in 1 of 1 tube fed patient in which the staff inappropriately turned off the tube feedings; the patient subsequently experienced significant loss of weight (Patient #1).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care.

Based on review of hospital documents and interview, it was determined that the hospital failed:

Tag A 0273

to maintain an effective data-driven quality program of quality assessment, when data over a 15 month period revealed that food temperatures out of specification for a safe range could potentially cause food-borne illness resulting in a risk of harm to the patients, and analysis of the data was not conducted: the governing body was provided the data, but failed to ensure that analysis of the dietary data was conducted.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality dietary health care.

Based on review of policies and procedures, job descriptions, facility documents, medical records, and interviews, it was determined that the hospital failed to have an organized dietary service as evidenced by:

Tag A 0622

1. failing to ensure that speciality diets for Long Term Acute Care (LTAC)patients contained the proper nutrients specific to the diet ordered for 10 of 10 patients (Pts # 2, 4, 11, 12, 13, 14, 15, 16, 17, and 18), which has a potential risk of harm to the patients if they are not provided required nutrients necessary to ensure proper healing in the disease process .

2. failing to assure that foods were served to patients at appropriate temperatures to avoid potential food-borne illness and risk of harm to the patients.

Tag A 0629

1. that the hospital failed to ensure that patients ordered a specialty diet received nutrition according to the specific dietary order in 10 of 10 patients ordered a specialty diet (Patients #2, 4, 11, 12, 13, 14, 15, 16, 17, and 18) which has a potential risk of harm to the patients if they are not provided the required nutrition identified in each specialty diet; and

2. that the hospital failed to meet the patient's needs in 1 of 1 tube fed patients in which the staff inappropriately turned off the tube feedings; the patient subsequently experienced significant loss of weight (Patient #1).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of dietetic services commensurate with the high-risk patient population of the Hospital.

Based on review of policy and procedure, record reviews, job description reviews, and interview, it was determined that the Chief Executive Officer (CEO) failed to be responsible for managing the hospital as evidenced by:

1. failing to ensure that a patient with multiple co-morbidities received a tube feeding as ordered, and failing to require staff to follow the hospital's policy that all disciplines function as a collaborative team; this resulted in a significant loss of weight to one of one patient (Patient #1);

2. failing to ensure that patients ordered a specialty diet received nutrition according to the specific dietary order in 10 of 10 patients ordered a specialty diet on 04-29-15 (Patients #2,4,5,6,7,8,9,10,11,and 12); and

3. failing to ensure that dietary data collected was analyzed to ensure that food temperatures over a 15 month period, which were out of specifications, could not cause food-borne illness in an at-risk population.

Findings include:

1. The "Patient Assessment, Reassessment and High Risk Screens" policy revealed: "...The assessment process will be a continuous, collaborative effort with all of the healthcare members functioning as a team. Communication among the healthcare team is an essential element of the assessment process. Patient assessment is a Multidisciplinary function...6. Dietician...c. The dietician will relay any information obtained via the assessment process to the appropriate health care discipline. d. Crucial to assessment/reassessment of the patient is the collaborative process of all health care providers. The dietician will interface, contribute, and advise all other health care providers to ensure that the patient is assured of the highest quality of nutritional care...."

The "LTAC-Dietician" job description revealed: "POSITION SUMMARY: The Dietician performs nutritional assessments of patients ranging in age from 18 years to geriatric...."

The "LTAC-RN" job description revealed: "POSITION SUMMARY": "The Registered Nurse, with appropriate competency completions, is responsible for the direct and indirect nursing care of all patients ranging in age from 18 years to geriatric experiencing medically complex conditions... The RN is also responsible for the overall direction and supervision of all patient care during his/her shift...."

The "Clinical Evaluation" for admission for Patient #1, an elderly male, dated 02-25-15 revealed that the patient had a pressure-related partial thickness wound on the right heel (Stage 0), a full thickness pressure-related wound on the sacrum (Stage 2), and a full thickness surgical wound (Stage 4) in the right groin.

Patient #1 was admitted to the Hospital on 03-03-15 from an acute care hospital. The "REASON FOR ADMISSION" included the following: "Acute respiratory failure, Chronic obstructive pulmonary disease, Sepsis (Recent), Congestive heart failure with ejection fraction of 40% (normal ejection fraction is between 55% and 75%), Infected aortic graft, status post surgery, Groin wound, Decubitus ulcer, and Status post Percutaneous Endoscopic gastrostomy (PEG). The "Past History" included: abdominal aortic aneurysm, coronary artery disease, peripheral vascular disease, renal failure, and status post nephrectomy.

The "Medical Nutrition Therapy-Initial Tube Feeding Evaluation," dated 03-05-15 and authored by Registered Dietician (RD)#1, revealed that Patient #1 was ordered Fibersource HN (high protein, fiber-containing tube feeding formula) via a PEG tube at 55 milliliters (ml) per hour. The decubitus ulcer was documented as a "Stage 3" on the back and coccyx (Full thickness tissue loss). The "Anthropometrics" revealed a height of 67 inches (5 feet, 7 inches), a weight of 170/77.32 kg (170 pounds and 77.32 kilograms) "transfer-wt. (weight) pounds (weight at the time of transfer to the LTAC from the acute care hospital), and a Body Mass Index (BMI) of 19.1. The "Estimated Nutrient Needs" revealed that the patient needed 1932 calories per day. The "Wt used in calculations" was "77.3 kg (kilograms)." RD #1 documented that the patient's "weight status" was: "Within Ideal Weight Range." The "Intervention" revealed: "...Goals"...Weight." Handwritten in by the RD was "Need a current weight."

Actual weights recorded on the "Medical Nutrition Therapy Tube Feeding Progress Notes" and in "Medical Nutrition Therapy Progress Notes" revealed the following weights:

03-06-15 135.0 pounds
03-08-15 128.8 pounds
03-13-15 114.0 pounds
03-23-15 114.4 pounds
03-24-15 115.6 pounds
03-29-15 97.4 pounds
04-01-15 109.0 pounds

On 03-23-15 RD #1 documented: "New weight obtained today 114.4 lbs...Last weight noted 128.8 lbs 3/8 Patient needs to be weighed on same scale to determine actual weight. Patient has been receiving 37 kcal (kilocalorie) at current rate of 65 ml/ (milliliters) (symbol for hour depicted). Many times tube feeding is not infusing as therapy (physical therapy) gets patient up for therapy, and tube feeding is off. Have talked with nursing staff about hooking tube feeding back up. Will increase rate to 70 ml/(symbol for hour).

On 03-26-15 RD #1 documented: "...RD discussed with PT (physical therapy) that TF (tube feeding) should not be turned off during therapy...."

On 03-30-15 RD #1 documented: "...Question validity of current weight, will have Pt. reweighed. RD will increase TF to 75 ml/(symbol for hour) to provide pt. c (with) 41.5 kcals/kg, 2160 total kcals, 109 g (grams) Pro (protein), 1638 ml of water as Pt. is very active, constantly moving and appears very thin and not gaining weight...."

A facility document revealed: "(Patient #1) was re-weighed...2 April 2015. At that time he weighed 110.8 lbs. (pounds)...A review of documented weights showed an inaccurate weight from admission. The admitting nurse did not weigh (patient), but instead took the weight from the clinical liaison's evaluation from the referring hospital which was 170 lbs. on 02-25-15. The first weight obtained at Cornerstone hospital of Southeast Arizona was 135.0 lbs.

The Quality Director stated, during interview conducted on 04-29-15 at 10:40 A.M., that the patient was not weighed upon admission. The Director stated that the weight documented at admission was apparently the weight at which the patient had been when he was admitted to the acute care hospital, which was likely much higher than the real admission weight. The Director stated that although there was not a written policy that patients be weighed at admission, there was a substantive policy, and the patient should have been weighed at the time of admission.

RD #1 stated, during interview conducted on 04-06-15 at 11:45 A.M., that the patient was provided a nutritional assessment within 48 hours of admission, and that Patient #1 was in an extreme catabolic (wasting) state. RD #1 stated that the "problem" was that the patient's tube feeding was off "quite a bit." RD #1 stated that she made nursing staff and physical therapy staff aware that the tube feeding was continuous and should not be turned off, but to no avail.

2. Refer to Tag A 0622 relative to food temperatures out of specifications for a safe range over a 15 month period which were not analyzed.

3. Refer to Tag A 0629 relative to the failure of the Hospital to provide specialized diets as ordered in an at-risk population.

Based on review of hospital documents and interview, it was determined that the quality program failed to include an ongoing program to show measurable improvement in food temperatures to prevent potential food-borne illness in a high-risk patient population; the data collected was not used to monitor the safety of dietary services.

Findings include:

Refer to Tag A 0629 relative to the hospital's failure to provide therapeutic diets according to the diet order.

Refer to Tag A 0622 relative to the hospital's failure to ensure the prevention of food-borne illness when food temperatures were out of specifications over a 15 month period from January, 2014 through March, 2015.

The Director of Quality stated, during interview conducted on 05-05-15 at 8:30 A.M., that the Quality Committee at the hospital was comprised of the Chief Executive Officer (CEO), the Chief Clinical Officer (Director of Nursing), the Medical Director, and the Quality Director. The Director stated that the 2015 Quality Plan was approved by the Quality Committee. The Director stated that there was no key quality indicator for Dietary Services approved for 2015 on 03-20-15. The Director stated that the Medical Executive Committee (MEC) approved the 2015 Quality Plan on 03-24-15. The Director stated that the governing body (GB) for the hospital was comprised of the CEO and the President of the Medical Staff.

The Quality Director stated that the Strategic Quality Plan is generated by the corporation, and for CHG Hospital of Tucson, the key quality corporate indicator for "kitchen" was refrigerator temperatures. The Director stated that there had not been a problem with refrigerator temperatures, but that had always been a corporate key quality indicator for the hospital.

The Director stated that de facto dietary indicators were taste, temperature, portion sizes, and appearance of the food. The Director stated that dietary data is presented to the Quality Committee and MEC monthly, and to the GB quarterly.

RD #1 stated, during interview conducted on 04-29-15, that if the actual food temperatures were not 90% or greater of required temperature, it could put patients at risk. RD #1 stated that the patients at the LTAC are immunocompromised, so correct food temperatures are particularly important.

The Director stated, during interview conducted on 04-29-15 at 1:50 P.M., that prior to the survey, she was not aware of any issues in the dietary department. The Quality Director acknowledged that she was unaware that the food temperatures reported for 15 months could have potentially caused food-borne illness. The Quality Director acknowledged that no member of the Quality Committee, MEC, or Governing Body questioned the significance of the dietary data including food temperatures.

Based on review of policies and procedures, job descriptions, and interview, it was determined that the hospital failed to ensure that the hospital's dietary personnel were competent in their respective duties as evidenced by;

1. failing to ensure that speciality diets for Long Term Acute Care (LTAC) patients contained the proper nutrients specific to the diet ordered for 10 of 10 patients (Pts # 2, 4, 11, 12, 13, 14, 15, 16, 17, and 18), which has a potential risk of harm to the patients if they are not provided required nutrients necessary to ensure proper healing in the disease process .

2. failing to assure that foods were served to patients at appropriate temperatures to avoid potential food-borne illness and risk of harm to the patients.

Findings include:

1. Refer to Tag A 0629 relative to the hospital's inability to ensure specialty diets were as ordered, when the Dietary Manager prepared diets without following the recipes approved by a Registered Dietician.

2. The [facility name] hospital "Temperature & Scoring Guide" revealed the temperatures to which the patients' food was appropriately heated or cooled.

Soups, Cereals, Hot Beverages >150 degrees Fahrenheit
Hot Entrees, Eggs, Starches &Vegetables >130 degrees Fahrenheit
Fruits & Desserts < 50 degrees Fahrenheit
Salads & Potentially Hazardous Cold Foods <45 degrees Fahrenheit
Milk, Dairy Products & Cold Beverages <41 degrees Fahrenheit

Review of test tray analysis for 2014 revealed the following temperature percentages of acceptable limitations for hot and cold foods:

January 2014 24%
February 2014 33%
March 2014 91%
April 2014 79%
May 2014 88%
June 2014 84%
July 2014 59%
August 2014 80%
September 2014 81%
October 2014 69%
November 2014 72%
December 2014 71%

Annotation on the Test Tray Analysis for 2014 revealed:

January: "There was a small improvement in temperature...Collaborate with chef (name) to provide more training to cooks and diet aides...."

February: "Further improvement was noted with temperatures...Further training of diet aides & cooks...."

March: "...2 of the 7 trays contained foods with unacceptable temps (temperatures)...."

April: "The temp and taste scores decreased...."

May: "All areas improved except portion sizes...."

June: "Temp scores decreased slightly...."

July: "Significant decrease in temperature score. Spoke with Chef-possibly r/t (related to) increased census, inefficiency with tray line, diet aides not receiving assistance when delivering trays. There was also a decline in taste-this could be partly related to temps...."

August: "Improvement with temperatures...."

September: "no improvement with temperatures...."

October: "Significant decrease in temperature score. Spoke with kitchen staff regarding this and there is inconsistency with the cooks in how the food is being served...."

November: "Temperatures remain a problem...."

December: "temperatures remain a problem...."

Review of test tray analysis for 2015 revealed the following temperature percentages of acceptable limitations for hot and cold foods:

January 2015 67%
February 2015 56%
March 2015 46%

Annotation on the 2015 Test Tray Analysis revealed:

January: "The temperature scores decreased again...."

February: "The temperature scores decreased again...."

March: "Temperatures decreased...."

Registered Dietician #1 stated, during interview conducted on 4-29-15 at 2:07 P.M., that if the food temperatures are not maintained at 90% or greater (of appropriate temperatures), it can place the patient at risk (for food-borne illness). The RD stated that in the patient population served by the hospital, appropriate food temperatures are important.

Based on review of medical records, policies and procedures, personnel file review, job description review, and interview, it was determined:

1. that the hospital failed to ensure that patients ordered a specialty diet received nutrition according to the specific dietary order in 10 of 10 patients ordered a specialty diet (Patients #2, 4, 11, 12, 13, 14, 15, 16, 17, and 18) which has a potential risk of harm to the patients if they are not provided the required nutrition identified in each specialty diet; and

2. that the hospital failed to meet the patient's needs in 1 of 1 tube fed patient in which the staff inappropriately turned off the tube feedings; the patient subsequently experienced significant loss of weight (Patient #1).

Findings include:

1. The "Lead Dietary" (Director) job description revealed: "POSITION SUMMARY": The Lead, Dietary oversees the nutritional assessments and integrates nutritional therapy of patients ranging in age from 18 years to geriatric. Monitors nutritional care, manages physician ordered therapeutic diets and provides nutritional education to patients..."MINIMUM QUALIFICATIONS" Knowledge of regulatory standards and compliance requirements...."

The "Diet Orders and Diet Changes" policy revealed: "...3. All diet orders must correspond with the diets outlined in the diet manual...."

The "Portion Control" policy revealed: "PURPOSE": To ensure proper food portioning to control food costs and adhere to modified diets. PROCEDURE: 1. Dietary Supervisor will write proper portion size of food items on the menu spreadsheets. 2. Cooks and Dietary Aides will adhere to these portion sizes when preparing trays or serving on the tray line...."

The "Preparation" policy revealed: "PURPOSE": To ensure that all food is prepared according to standardized recipes in a safe and sanitary manner... PROCEDURE: 1. Prepare all food according to the standardized recipes and or the instructions on the container...."

The "Diet Descriptions-[facility name] Hospital Group" "Cardiac" diet "Description" revealed that a patient on a cardiac diet would have: "10% saturated fat 0% hydrogenated fat, 3 gram sodium, high Fiber, decreased refined carbohydrates."

On 04-29-15, the hospital's census was 18. Review of the diets ordered for the patients revealed that of the 18 patients, 10 patients were on specialty diets, 4 patients were on tube feedings, 1 patient was on Total Parenteral Nutrition (TPN), and 3 patients were on a regular diet. The patient diagnoses and specialty diets were as follows:

1. Patient #2 Respiratory Failure; Pulmonary Edema 1800 calorie ADA (American Diabetic Association)

2. Patient #4 Non-Healing Toe Ulcer with Osteomyelitis and Cellulitis 1800 calorie ADA

3. Patient #11 Respiratory Failure on ventilator 1800 calorie ADA

4. Patient #12 Necrotizing Pancreatitis 2200 calorie ADA Thin Liquids

5. Patient #13 Osteomyelitis with Vancomycin Resistant Staphylococcus High Protein Diet

6. Patient #14 Large Portion of Bowel Removed (Extensive Operating Room Procedure) Mechanical Soft; No concentrated sweets

7. Patient #15 Diabetes Mellitus; Acute Cellulitis with Gangrene 1800 calorie ADA, High Protein

8. Patient #16 Respiratory Failure; Pulmonary Edema 2000 calorie ADA, Mechanical Soft

9. Patient #17 Diabetes Mellitus; Multiple Acquired Pressure Ulcers 1800 calorie ADA, Mechanical

10. Patient #18 Other Infectious and Parasitic Disease Mechanical Soft, Boost (Medical Nutritional supplement)

Patient #2, an elderly male, was admitted to the Long Term Acute Care Hospital (LTAC) on 04-08-15. The "History of Present Illness" revealed: "...was driving through Arizona returning to his home in (state) when he suffered a myocardial infarction (heart attack) on 03-14-15. He was hospitalized since then at (local acute care hospital) on a ventilator. He already has a 15-year history of marked congestive heart failure following an MI (myocardial infarction) at age 45, and his hospitalization was complicated by pneumonia and further CHF. He was on a ventilator for 2 weeks until 3-28. He had acute kidney injury superimposed on chronic kidney disease stage 4, leading to the need for hemodialysis until 3-27. He had a history of poorly controlled diabetes. At the present time, he still has high oxygen demand, requiring high-flow oxygen by nasal cannula... He has also developed Clostridium difficile colitis... He states that he has not been out of bed over the past nearly month of hospitalization...The "Past Surgical History" revealed: "Coronary artery bypass graft (CABG)...."

The admission orders revealed an order for a Cardiac ADA (American Diabetic Association) diet with thin liquids." On 04-13-15 the patient was ordered (arrow up indicating 'increase') Lasix (diuretic) po B.I.D. (twice per day). Cardiac diet (illegible) <2 grams NA (sodium) daily." On 04-21-15, the patient was ordered: "1700 ml (milliliters) po (by mouth) fluid restriction."

The "Physician Progress Notes dated 04-13-15 revealed: "...Complained of high salt content of food...."

Test Tray Evaluations in April, 2015, revealed annotations as follows:

04-13-15: "Soup was a little salty"
04-16-15: "Gravy a little salty"
04-23-15: "...Rice and gravy were salty...."

Patient #2 stated, during interview conducted on 04-29-15 at 11:05 A.M., that there has been slight improvement in the sodium content of his hospital diet since his family complained, but there is still "too much" sodium in his food.

During interview with Patient #2, a staff member from the Physical Therapy department responded to the patient's request for more water. The staff member returned with a pitcher filled with ice and water, making it difficult to ascertain how much actual fluid was added to the patient's restricted fluid intake.

Registered Dietician (RD) #1 stated, during interview conducted on 04-29-15 at 11:15 A.M., that she had met with the Chief Executive Officer, the Chief Nursing Officer, and the Human Resources Director several months prior to the survey, and told them that the portion sizes had to be standardized to meet the specifications of specialized diets. RD #1 stated that, as an example, there was no method to determine how much sodium a patient on a Low Sodium diet was getting in their meals, and that the Dietary Manager altered the recipes after the nutritional content had been assessed, making the actual nutritional content of any specialized diet unable to be determined with any accuracy.

2. The "Patient Assessment, Reassessment and High Risk Screens" policy revealed: "...The assessment process will be a continuous, collaborative effort with all of the healthcare members functioning as a team. Communication among the healthcare team is an essential element of the assessment process. Patient assessment is a Multidisciplinary function...6. Dietician...c. The dietician will relay any information obtained via the assessment process to the appropriate health care discipline. d. Crucial to assessment/reassessment of the patient is the collaborative process of all health care providers. The dietician will interface, contribute, and advise all other health care providers to ensure that the patient is assured of the highest quality of nutritional care...."

The "LTAC-Dietician" job description revealed: "POSITION SUMMARY: The Dietician performs nutritional assessments of patients ranging in age from 18 years to geriatric.

The "LTAC-RN" job description revealed: "POSITION SUMMARY": "The Registered Nurse, with appropriate competency completions, is responsible for the direct and indirect nursing care of all patients ranging in age from 18 years to geriatric experiencing medically complex conditions... The RN is also responsible for the overall direction and supervision of all patient care during his/her shift...."

The "Clinical Evaluation" for admission for Patient #1, an elderly male, dated 02-25-15 revealed that the patient had a pressure-related partial thickness wound on the right heel (Stage 0), a full thickness pressure-related wound on the sacrum (Stage 2), and a full thickness surgical wound (Stage 4) in the right groin.

Patient #1 was admitted to the hospital on 03-03-15, from an acute care hospital. The "REASON FOR ADMISSION" included the following: "Acute respiratory failure, Chronic obstructive pulmonary disease, Sepsis (Recent), Congestive heart failure with ejection fraction of 40% (normal ejection fraction is between 55 and 75), Infected aortic graft, status post surgery, Groin wound, Decubitus ulcer, and Status post Percutaneous Endoscopic gastrostomy (PEG). The "Past History" included: abdominal aortic aneurysm, coronary artery disease, peripheral vascular disease, renal failure, and status post nephrectomy.

The "Medical Nutrition Therapy-Initial Tube Feeding Evaluation," dated 03-05-15, and authored by Registered Dietician (RD)#1, revealed that Patient #1 was ordered Fibersource HN (high protein, fiber-containing tube feeding formula) via a PEG tube at 55 milliliters (ml) per hour. The decubitus ulcer was documented as a "Stage 3" on the back and coccyx (Full thickness tissue loss). The "Anthropometrics" revealed a height of 67 inches (5 feet, 7 inches), a weight of 170/77.32 kg (170 pounds and 77.32 kilograms) "transfer-wt. (weight) pounds (weight at the time of transfer into the LTAC from the acute care hospital), and a Body Mass Index (BMI) of 19.1. The "Estimated Nutrient Needs" revealed that the patient needed 1932 calories per day. The "Wt used in calculations" was "77.3 kg (kilograms)." RD #1 documented that the patient's "weight status" was: "Within Ideal Weight Range." The "Intervention" revealed: "...Goals"...Weight." Handwritten in by the RD was "Need a current weight."

Actual weights recorded on the "Medical Nutrition Therapy Tube Feeding Progress Notes" and in "Medical Nutrition Therapy Progress Notes" revealed the following weights:

03-06-15 135.0 pounds
03-08-15 128.8 pounds
03-13-15 114.0 pounds
03-23-15 114.4 pounds
03-24-15 115.6 pounds
03-29-15 97.4 pounds
04-01-15 109.0 pounds

On 03-23-15 RD #1 documented: "New weight obtained today 114.4 lbs...Last weight noted 128.8 lbs 3/8 Patient needs to be weighed on same scale to determine actual weight. Patient has been receiving 37 kcal (kilocalorie) at current rate of 65 ml/ (milliliters) (symbol for hour depicted). Many times tube feeding is not infusing as therapy (physical therapy) gets patient up for therapy, and tube feeding is off. Have talked with nursing staff about hooking tube feeding back up. Will increase rate to 70 ml/(symbol for hour).

On 03-26-15 RD #1 documented: "...RD discussed with PT (physical therapy) that TF (tube feeding) should not be turned off during therapy...."

On 03-30-15 RD #1 documented: "...Question validity of current weight, will have Pt. reweighed. RD will increase TF to 75 ml/(symbol for hour) to provide pt. c (with) 41.5 kcals/kg, 2160 total kcals, 109 g (grams) Pro (protein), 1638 ml of water as Pt. is very active, constantly moving and appears very thin and not gaining weight...."

A facility documented revealed: "(Patient #1) was re-weighed... 2 April 2015. At that time he weighed 110.8 lbs. (pounds)...A review of documented weights showed an inaccurate weight from admission. The admitting nurse did not weigh (patient), but instead took the weight from the clinical liaison's evaluation from the referring hospital which was 170 lbs. on 02-25-15. The first weight obtained at [facility name] hospital of Southeast Arizona was 135. lbs.

The Quality Director stated, during interview conducted on 04-29-15, at 10:40 A.M., that the patient was not weighed upon admission. The Director stated that the weight documented at admission was apparently the weight at which the patient had been when he was admitted to the acute care hospital, which was likely much higher than the real admission weight. The Director stated that although there was not a written policy that patients be weighed at admission, there was a substantive policy, and the patient should have been weighed at the time of admission.

RD #1 stated, during interview conducted on 04-06-15 at 11:45 A.M., that the patient was provided a nutritional assessment within 48 hours of admission, and that Patient #1 was in an extreme catabolic (wasting) state. RD #1 stated that the "problem" was that the patient's tube feeding was off "quite a bit." RD #1 stated that she made nursing staff and physical therapy staff aware that the tube feeding was continuous and should not be turned off, but to no avail.